Building an Integrated Approach to Improvement with …app.ihi.org/FacultyDocuments/Events/Event-2206/Presentation-7920/... · Building an Integrated Approach to Improvement with

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Building an Integrated Approach to Improvement with Lean, Six Sigma, and theModel for Improvement

Robert Lloyd, Kathy Luther and Helen Zak

Sessions D18 & E18

These presenters have nothing to disclose

December 12, 2012

Faculty

Robert Lloyd, PhDExecutive Director Performance Improvement,

Institute for Healthcare Improvement

Kathy Luther, RNVice President,

Institute for Healthcare Improvement

Helen Zak, MS, President and COOThedaCare Center for Healthcare Value

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Discussion Topics

• Understanding the foundation for all improvement

• Comparing and contrasting Lean, Six Sigma and the Model for Improvement

• Assessing where you are in your journey

Questions for Organizational Dialogue

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The current quality improvement strategy/model(s) we follow in my organization allow(s) us to meet all of our strategic objectives and targets.

Strongly Agree Agree Not Sure Disagree Strongly Disagree

Our current quality improvement strategy/model provides an integrated approach to QI that is sustainable.


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5

Theoretical

Concepts

(ideas & hypotheses)

Interpretation

of the Results

(asking why?)

Information

for Decision

Making

Data

Analysis and

Output

Select &

Define

Indicators

Data

Collection (plans & methods)

Deductive Phase

(general to specific)

Inductive Phase

(specific to general)

Source: R. Lloyd Quality Health Care, 2004, p. 153.

Theory

and Prediction

The Scientific Method provides the foundation for all improvement

Source: Moen, R. and Norman, C. “Circling Back: Clearing up myths about the Deming cycle and seeing how it keeps evolving,” Quality Progress November, 2010:22-28.

Understanding the Timeline is Critical

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Adapted from material developed by R. Scoville, Ph.D., IHI Improvement Advisor

19th century Pragmatism played a major role in building knowledge for improvement

• Darwinian notions of variation, population, and selection infiltrated a wide range of disciplines:• Epistemology – C.S. Pierce

• Psychology – William James, Edward Thorndike

• Sociology and education – George Mead, John Dewey

• Development – J.Baldwin, J.Piaget

• Law – Oliver Wendell Holmes

• Philosophy – B. Russell, K. Popper, L. Wittgenstein

• Some key notions • Belief is observable only through action

• Action is inherently a ‘bet’ on its results

• Routinely successful action = ‘habit’ = ‘knowledge’

Charles S. Peirce (1839–1914)

The founder of American pragmatism. He wrote on

a wide range of topics, from mathematics, to logic,

semiotics and psychology.

William James (1842–1910)

An influential psychologist and theorist of religion, as

well as philosopher and a physician. First to be widely

associated with the term "pragmatism" due mainly to

Charles Peirce’s difficult personality.

“As a rule we disbelieve all the facts and theories for which we have no use.”

William James

Classical Pragmatists (1850-1950)

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C. I. Lewis (1883-1964)

Perhaps the most important American academic philosopher

active in the 1930s and 1940s. He was the founder of

conceptual pragmatism and made major contributions in

epistemology and logic, and, to a lesser degree, ethics. Lewis

was also a key figure in the rise of analytic philosophy in the

US. He also had a profound impact on Walter Shewhart and

subsequently Edwards Deming..

John Dewey (1859–1952)

Prominent philosopher of education, referred to his brand

of pragmatism as “instrumentalism. “

Classical Pragmatists (1850-1950)

Source: Moen, R. and Norman, C. “Circling Back: Clearing up myths about the Deming cycle and seeing how it keeps evolving,” Quality Progress November, 2010:22-28.

Understanding the Timeline is Critical

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1939

The Deming Wheel1. Design the product (with appropriate tests).

2. Make it; test it in the production line and in the laboratory.

3. Sell the product.

4. Test the product in service, through market research. Find out

what user think about it and why the nonusers have not bought it.

1950

Development of the Shewhart Cycle

1986

Source: Moen, R. and Norman, C. “Circling Back” Quality progress, November 2010: 22-28.

Walter A.

Shewhart

(1891 – 1967)

The Shewhart Cycle for Learning and Improvement

Act Plan

Study Do

Act – Adopt the

change, abandon it

or run through the

cycle again.

Plan – plan a

change or test aimed

at improvement.

Study – Examine the

results. What did we

learn? What went

wrong?

Do – Carry out the

change or test

(preferably on a

small scale).

(Deming, 1993)

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History of the Scientific Method, PDSA, Six Sigma & Lean

Bill Smith (1986)Motorola

Mikel Harry (1988)Motorola- MAIC

Forrest Breyfogle 111(1992)- Integration

Michael George (1991)-Integration

F.Taylor-The Principles of Scientific Management

(1911)

Toyoda Family(late 1940’s and

early 1950’s)

Taiichi Ohno 1950-1980Toyota Production System Womack & Jones

(Reference: Wortman, 2001)

Source: Moen, R. and Norman, C. “Circling Back: Clearing up myths about the Deming

cycle and seeing how it keeps evolving,” Quality Progress November, 2010:22-28.

Variations on a Theme

• Baldrige Performance Excellence Program

• European Foundation for Quality Management (EFQM)

• International Organization for Standardization (ISO)

• Lean Enterprise (Toyota Production System, TPS)

• Six Sigma Methodologies (Design for Six Sigma, DFSS)

• Model for Improvement (MFI)

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Similarities

Have disciplined processes and approaches

Rely heavily on detailed measures

– Lean– process steps, value

– Six Sigma – Defects per 1,000,000 opportunities

– MFI – Process, outcome measures

Have a specific language and tools

Have a long history in the field

– Lean – Japanese production -Toyota-healthcare

– Six Sigma – Japanese – Motorola, GE-healthcare

– MFI – Shewhart, Deming, Japanese Union of Scientists and

Engineers (JUSE)

Define

Six Sigma

Analyze

Measure

Improve

Control

Identify

Value

Understand

Value Stream

Eliminate

Waste

Establish

Flow

Enable Pull

Pursue

Perfection

Lean

Source: The Improvement Guide, API

Let’s now take a closer look at…

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Lean

… a set of concepts, principles and tools

used to create and deliver the most value from the customer’s perspective while

consuming the fewest resources…

Lean Enterprise Institute (lean.org)

Lean Organizations Deliver

…exactly what is needed, at the right time,

in the right quantity without defects, and

at the lowest possible cost…

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Time

The currency of lean is time.

As you take out waste in the process, you take out time.

The time for a lean transformation is dependent on the

energy and effort spent.

Lean is a long term strategy, takes time to change

culture.

Testing turn around time, OR utilization as classic

examples.

Lean Thinking

1. Specify value from standpoint of the customer.

2. Identify the value streamand remove wasted steps.

3. Cause the remaining steps to flow.

4. But only at the pull of the customer.

5. In pursuit of perfection.

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Lean Transformation of Culture

Implementation of ToolsToolsToolsTools

Supported by a Management SystemManagement SystemManagement SystemManagement System

Put in Place by Lean LeadersLean LeadersLean LeadersLean Leaders


Tools Systems Behaviors

• Value Stream Map

• Waste Elimination

• PDCA

• A3

• 5S

• Six Sigma

• Standard Work

• Improvement Events

• Visual Controls

• Kanban

• Andons

• Every employee is a

problem-solver.

• Managers solicit ideas from

employees and encourage

continuous improvement.

• Employees treated with

respect and challenged to

grow personally and

professionally.

• Transparency of results and

areas for improvement.

• Reward & Recognition

• Education & Training

• Empowerment &

Involvement

• Idea Generation

• Process Improvement

• Strategic Planning

• System wide

management and

reporting to track results.

• Use of voice of customer

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Current State Value Stream Map

Value Stream Mapping: Why?

Helps people understand how the process works now.

Helps people understand and reach agreement on how

well the process is working now.

Helps uncover waste and problems with flow in the

value stream.

Helps people reach agreement on what changes need

to be made to improve.

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Kaizen = Improvement

Application of Tool (Just do it!)

Rapid Improvement Event (RIE)

Value Stream Analysis (VSM or VSA)

Daily Continuous Improvement

Three Types of Work

Value Creating

Work

Incidental Work

Waste

Value Creating Work- work

that produces something of

value to the customer.

Incidental Work- work that

does not in itself provide value

to the customer, but is

necessary to do the value

creating work.

Waste- work that adds no

value to the customer.

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Things to Remember About Waste

Waste is anything other than the minimum amount of

equipment, materials, technology, space, and a worker’s

time that are essential to add value to the product or

service.

Waste is a symptom, not a cause.

Waste points to an underlying problem within the system.

8 Categories

IHI’s Waste Reduction Tool





• PDCA

• A3

• 5S

• Six Sigma

• Standard Work


• Visual Controls

• Kanban

• Andons


problem-solver.






grow personally and

professionally.





• Empowerment &

Involvement

• Idea Generation

• Communication


• System wide

management and



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What is A3?

• A3 is simply a paper size (international 11 x 17).

• A3 planning began in the 60’s as the Quality Circle problem-solving format using pdca.

• At Toyota, it evolved to become the standard format for problem-solving, proposals, plans, and status reviews.

An A3 Format

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• PDCA

• A3

• 5S

• Six Sigma

• Standard Work


• Visual Controls

• Kanban

• Andons


problem-solver.






grow personally and

professionally.





• Empowerment &

Involvement

• Idea Generation

• Communication


• System wide

management and



Lean Leadership (Behavior)

Guiding Principle = Problems are Treasures

Guiding Principle = A Leader’s Job is to

Develop People (not “manage” them)

Guiding Principle = Go to the Gemba!

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…Kaplan tours the hospital daily looking for problems and solutions. Everyone is encouraged to look for changes to make work more efficient…

-Virginia Mason CEO Gary Kaplan

Gemba= Place Where Value is Created

“Once leaders start spending more of their time out where the work is being done in their organization watching what is going on, they will be surprised what they learn.”

-Sarah Patterson, EVP and COO, Virginia Mason

Define

Six Sigma

Analyze

Measure

Improve

Control

Identify

Value

Understand

Value Stream

Eliminate

Waste

Establish

Flow

Enable Pull

Pursue

Perfection

Lean


Now let’s move over to look at…

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Six Sigma Overview

• Process Improvement set of tools and strategies

• Developed by Motorola in 1986

• Business strategy- Jack Welch, General Electric-1995

• Improve quality by:

• Identifying and removing causes of defects (errors)

• Minimizing variability in processes

• Uses a set of statistical methods

• Creates an infrastructure

• Champions, Black Belts, Green Belts, Orange Belts, etc.

• Each project: disciplined sequence and financial targets

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Six Sigma: When and What? 36

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Six Sigma Specifics

Define problem in detail

Measure a “defect”. Turn into “defects per million” - -

Sigma Level

Analyze In-depth analysis using process measures, flow

charts, defect analysis to determine under what conditions

defects occur

Improve Define and test changes aimed at reducing

defects

Control What steps will you take to maintain performance

Define

DMAIC - steps

Analyze

Measure

Improve

Control

Tools: Flow charts, process maps, Prioritization matrix, force field analysis, etc.

Six Sigma Level

Define

DMAIC

Analyze

Measure

Improve

Control

Sigma LevelDefects Per Million Opportunities (DPMO)

1 690,000

2 308,537

3 66,807

4 6,210

5 233

6 3.4

Example: Ventilator Associated Pneumonia (VAP)

Defect = 1 VAP Opportunity = 1 Vent Day

1 VAP per 500 vent days = 2000 per 1,000, 000 (DPMO)

4.38 – Sigma Level

4.38

What if? • Surgical site infections are 10 per quarter

• BSIs are 8 per line day

• VAPs are 3 per 1000 line days

• Only 6 days have gone by without a “never event”

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Define

Six Sigma

Analyze

Measure

Improve

Control

Identify

Value

Understand

Value Stream

Eliminate

Waste

Establish

Flow

Enable Pull

Pursue

Perfection

Lean


Finally, let’s look at the…

The Improvement Guide, API, 2009

The Model for Improvement

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41

Involve senior leaders

• Obtain sponsorship (geared to the project’s complexity)

• Provide frequent and brief updates(practice the 2 minute elevator speech)

Focus on issues that are important to your organization

• Connect the team Aim Statement to the Strategic Plan

• Build on the work of others (steal shamelessly!)

Aim Statement(What are you trying to improve?)

Aim Statement for the IHI Hospital Acquired

Infections Community:

Overall, to reduce infections from MRSA, VRE and C. diff

by 30% within 12 months.

Example #1 of an Aim Statement

How good? By When?

Hope is not a plan!

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Outcome Measures: Voice of the customer or patient. How is the system performing? What is the result?

Process Measures: Voice of the workings of the system. Are the parts/steps in the system performing as planned?

Balancing Measures: Looking at a system from different directions/dimensions. What happened to the system as we improved the outcome and process measures (e.g. unanticipated consequences, other factors influencing outcome)?

Three Types of Measures

The Improvement Guide, API, 2009


Now, let’s focus on the PDSA part of the MFI and

tests of change

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Plan• Objective

• Questions &

predictions

• Plan to carry out:

Who?When?

How? Where?

Do• Carry out plan

• Document

problems

• Begin data

analysis

Act• Ready to

implement?

• Try something

else?

• Next cycle

Study• Complete data

analysis

• Compare to

predictions

• Summarize

What will happen if we try something

different?

Let’s try it!Did it work?

What’s next?

The PDSA Cycle for Learningand Improvement

The Sequence for Improvement

Sustaining improvements and Spreading changes to other locations

Developing a change

Implementing a change

Testing a change

Act Plan

Study Do

Theory and Prediction

Test under a variety of conditions

Make part of routine operations

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47Guidance for Testing a Change Concept

A test of change should answer a specific question!

A test of change requires a theory and a prediction!

Test on a small scale and collect data over time.

Build knowledge sequentially with multiple PDSA

cycles for each change idea.

Include a wide range of conditions in the sequence

of tests.

Don’t confuse a task with a test!

To Be Considered a Real Test

Test was planned, including a plan for collecting data

Plan was carried out and data were collected

Time was set aside to analyze data and study the results

Action was based on what was learned

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How well do you develop innovative ideas?

Central Line Insertion Bundle

Maintenance Bundle

Partner with Accident and Emergency and Operating Theatres for Standardisation

Standardise Process:Line Carts and Dressing Kits

Aim: Reduce Complications from CLABSIs in Hospital X, Pilot Site by March 2012

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The Sequence for Improvement

Sustaining improvements and Spreading changes to other locations

Developing a change

Implementing a change

Testing a change

Act Plan

Study Do

Theory and Prediction

Test under a variety of conditions

Make part of routine operations

Factors that Determine Success

Current Situation Resistant Indifferent Ready

Low Confidence that current change idea will lead to Improvement

Cost of failure large

Very Small

Scale Test

Very Small

Scale Test

Very Small

Scale Test

Cost of failure small

Very Small

Scale Test

Very Small

Scale Test

Small Scale

Test

High Confidence that current change idea will lead to Improvement

Cost of failure large

Very Small

Scale Test Small Scale

Test

Large Scale

Test

Cost of failure small

Small Scale

Test

Large Scale

TestImplement

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“The main criterion for choosing a quality

system is how well it serves the needs of the

Gemba”

Reference: Kelly Allen, “Get Into Gemba” Quality Progress April, 2004

Looking beyond the Forum!

Gemba (the real place)• Literally translated to mean “The place of specific work” or “the “real place”

• Peter Scholtes (The Leader’s Handbook, McGraw-Hill, 1998) defines it as “the

critical resources and sequence of interdependent activities that add value to the

customer.”

• The Gemba for a manufacturing company could include product design and

development, production, delivery and maintenance.

• The Gemba for a service organization might include service design, development

and delivery, flow and customer service.

• In healthcare, Gemba could include a clinic visit with the physician, the physical

therapy department, an OR procedure, the patient’s room or a home care visit.

• Activities related to finance, HR and IT are NOT Gemba but should support the

Gemba.

• Understanding your organization's Gemba will help you decide which quality

system or approach is most appropriate.

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Let Gemba help guide your decision!

If… Then…there are specific opportunities for further improvement in quality to reduce waste, improve turnaround time

Lean could best serve the Gemba

there are specific opportunities for further improvement in quality to have fewer defects or improve reliability of performance

Six Sigma could best serve the Gemba

the organizational components/units or system are in need of improvement, breakthrough thinking, innovation and/or spread

the Model for Improvement (MFI) could best serve the Gemba

In short, the choice of a quality system,

approach or model should be driven by

the objectives of the organization, its

culture and its Gemba!

The decision should NOT be driven by

how popular a particular approach is or

even if it has been used successfully in

other settings.

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ExerciseUnderstanding your Gemba

1. Form small groups (about 8-10 people).

2. Each individual should write down what they think the

Gemba of their unit or department is and then identify the

Gemba of the entire organization (don’t talk to anyone

while doing this).

3. Next, note some of the areas that support the Gemba.

Use the worksheet provided on the next page.

4. As a group, discuss your individual ideas about Gemba

and note similarities and differences within your group’s

responses.

Gemba Exercise Worksheet

The Gemba of my unit or

department is…

The Gemba of my organization is…

Units and departments that

support the Gemba are…

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Now, combine your knowledge of Gemba with the review of the approaches described earlier in this Workshop and

complete the worksheet on the next page.

Use the following questions to guide your work:

1. Can you evaluate your current approach or model to QI in light of what you

have learned?

2. If not, what more do you need to learn about the different approaches to decide

how to proceed?

3. Does your current approach or model allow you to successfully achieve your

Gemba?

4. What are some of the advantages and disadvantages of each approach for

your organization?

Exercise: Selecting an Approach

What will work best for your Gemba?

Quality Approach

Advantages Disadvantages

Six Sigma

Lean


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Let’s revisit the Questions for Organizational Dialogue

61

The current quality improvement strategy/model(s) we follow in my organization allow(s) us to meet all of our strategic objectives and targets.


Our current quality improvement strategy/model provides an integrated approach to QI that is sustainable.


Constancy of purpose

Having a theory

Building capacity & capability

The Keys to Excellence

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“The greatest thing in the “The greatest thing in the “The greatest thing in the “The greatest thing in the world is not so much where world is not so much where world is not so much where world is not so much where

you stand, as in what you stand, as in what you stand, as in what you stand, as in what direction we are moving.”direction we are moving.”direction we are moving.”direction we are moving.”

~Oliver Wendell Holmes

Where are you headed?

64Thanks for joining us today.

Good luck with your Quality Journey!

Robert Lloyd

[email protected]

Kathy Luther

[email protected]

Helen Zak

[email protected]

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“Quality begins with intent, which is

fixed by management.”

W. E. Deming, Out of the Crisis, p.5